Sepsis, critical illness, communication, swallowing and Sustainable Development Goals 3, 4, 10

Abstract

Purpose

Sepsis is a major global health problem with an estimated 49 million cases globally each year causing as many as 11 million deaths. The primary objective of this commentary is to describe the impacts of sepsis and critical illness on communication and swallowing function, and to discuss management strategies considering the Sustainable Development Goals (SDGs).

Result

Communication and swallowing disabilities can occur with sepsis and critical illness. A holistic framework to optimise function, recovery, and future research priorities across the lifespan can be developed through the SDGs.

Conclusion

Communication and swallowing disabilities following critical illness associated with sepsis have global impacts. Early multidisciplinary engagement is key to optimising individuals’ function. Collaborative research, education, and public awareness is urgently needed to increase equity in health outcomes across populations. This commentary paper supports progress towards good health and well-being (SDG 3), quality education (SDG 4) and reduced inequalities (SDG 10).

Keywords:

• Sustainable Development Goals (SDGs)
• good health and well-being (SDG 3)
• quality education (SDG 4)
• reduced inequalities (SDG 10)
• communication disability
• swallowing disability
• sepsis
• critical care

Background

Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to severe infection (Singer et al., 2016), meaing the body starts attacking its own tissues and organs in response to the infection. Infections leading to sepsis can occur from a variety of sources but commonly include the chest (e.g. pneumonia), renal disease and skin infections. As the leading cause of critical illness across the globe (Rudd et al., 2020), sepsis affects people across the lifespan including children and adults, and often necessitates delivery of high-level healthcare within an intensive care unit (ICU). Declared by the World Health Assembly as a global epidemiological burden (World Health Organization, 2017), the implementation of evidence-based targeted prevention, treatment and survival efforts from sepsis is an international responsibility (Evans et al., 2021). The United Nations 2030 Agenda for Sustainable Development and its 17 Sustainable Development Goals (SDGs, United Nations, 2015) aim to promote partnership and collaboration to address global issues. Communication and swallowing disability can occur before, during or after a diagnosis of sepsis, and often persist for extended periods. A holistic framework to optimise function, recovery and future research priorities can be developed through considering three of the SDGs. This commentary focuses on ensuring healthy lives and promote well-being (SDG 3) for all at all ages; ensuring inclusive and equitable quality education (SDG 4) and promote lifelong learning opportunities for all; and reduced inequality (SDG 10) within and among countries. This paper identifies key issues and offers focussed solutions across high-, middle- and low-income countries to address the global problem of sepsis and its impacts on communication and swallowing functions.

Good health and well-being

Annually, an estimated 49 million people worldwide acquire sepsis, with many requiring admissions to an ICU with ongoing use of health care in their journey towards recovery (Rudd et al., 2020). Sepsis affects people of any age across the lifespan, and is one of the primary causes of neonate morbidity worldwide (Kurul et al., 2022) and accounts for almost 20% of all reported deaths (Rudd et al., 2020). Sepsis incurs high healthcare costs, accounting for $38.2 million (USD) or 8.8% of total hospital expenditure (Liang et al., 2020). High level care, including use of mechanical ventilation, is required to support and sustain the lives of patients who are critically ill with sepsis. Forms of invasive mechanical ventilation, including endotracheal intubation (i.e. oral or nasal) and insertion of tracheostomy tubes, negatively impacts communication function, limiting patients’ ability to engage actively and participate in their care (Freeman-Sanderson et al., 2018). For neonates, this can impact acquisition of speech, language and commuication skills (Harding et al., 2022). The impact and cost of altered communication in the ICU is not known, as there is no specific international classification of disease (ICD-10) code assigned to this iatrogenic communication disability. Focused communication interventions are needed to enrich environments and empower patients to participate and communicate with health care providers and their families earlier in ICU and throughout their hospital admission. Earlier interventions contribute to good health and well-being (SDG 3), in that effective communication is integrally related to: (a) health literacy, access to health services, diagnosis, and healthcare interactions and (b) patient safety and satisfaction with healthcare experiences.

In ICU, targeted communication interventions developed in collaboration with speech–language pathologists (SLPs) in a multidisciplinary environment supports and increases patient well-being and health-related quality of life (Freeman-Sanderson et al., 2016; Freeman-Sanderson et al., 2018; Happ et al., 2014; Martin et al., 2021; Rose et al., 2021; Sutt et al., 2020). However, there is variation in interventions enabling communication their and outcomes in this population (Rose et al., 2021). Pivotal to health, well-being and participation is the ability to eat and drink safely. Swallowing function is impacted by the use of mechanical ventilation, with strong evidence suggesting increased incidence and risk of aspiration (Brodsky et al., 2018; Krisciunas et al., 2020; Plowman et al., 2021) with acknowledgment for multidisciplinary management including SLPs (Brodsky et al., 2020). In a critically ill cohort of patients, risk of aspiration was 2.7 times higher in patients with sepsis; and sepsis was identified as an independent risk factor for prolonged use of enteral feeding and tracheostomy tube cannulation at 4-months post-ICU admission (Zielske et al., 2014). Moreover, a diagnosis of sepsis during ICU is an independent factor for new and long-term persistent functional impairment on daily activities of living for sepsis survivors (Higgins et al., 2021). Beyond hospital admission, sepsis has impacts on community participation and economy due to a protracted recovery journey including reduction in workforce engagement (Hodgson et al., 2017). There is an opportunity for further research informed by the biopsychosocial model of the International Classification of Functioning, Disability and Health (ICF, World Health Organization, 2001), to more fully appreciate and understand the characteristics and impact of communication and swallowing disabilities on well-being after sepsis.

SDG4: Quality education (SDG 4)

The Surviving Sepsis Campaign (Evans et al., 2021) addresses quality education (SDG 4), through promotion and access to best practice guidance that can be implemented across the continuum of sepsis care. The international campaign provides an open access set of evidence-based guidelines and clinical recommendations for the recognition, treatment and management of patients with sepsis admitted to an acute care setting (Evans et al., 2021). Whilst focused for provision of adult care, the campaign is applicable across the lifespan to raise public awareness, improve healthcare education for patients and carers on importance of enhancing patient communication to empower active participation in shared decision making. A specific set of evidence-based guidance for caring for children with sepsis are also freely accessible (Weiss et al., 2020).

SDG 10: Reduced inequalities (SDG 10)

Globally, the incidence of sepsis is higher in females, although mortality due to sepsis is more common among men (Rudd et al., 2020). Incidence is also higher in continents with a low- and low-middle socio-demographic index (Rudd et al., 2020), demonstrating an urgent need for improved healthcare systems that promote equality and equity. There is emerging evidence that some populations are less well considered than others in sepsis research. In Australia, there is a higher incidence of sepsis and ICU admission for Aboriginal and Torres Strait Islander peoples, with those admitted to hospital being younger in age than non-Indigenous Australians (Thompson et al., 2021). In India, over half of all patients admitted to ICU were diagnosed with sepsis, highlighting a significant burden and equality gap in low- and middle-income countries (Hammond et al., 2022). The importance of SLPs being included in ICU teams (Brodsky, Mayfield, & Gross, 2019; Brodsky et al., 2014; Freeman-Sanderson et al., 2020), rapid ICU surges such as COVID-19 (Ridley et al., 2021), and post-ICU rehabilitation programmes to deliver care and improve patient outcomes is accepted (National Post-Intensive Care Rehabilitation Collaborative, 2020). However, access to SLP services in the ICU, including dedicated SLP positions in the ICU, is not equitable across the globe (Cardinal et al., 2020; Macht et al., 2012; Spronk et al., 2022; Zuercher et al., 2019).

Summary and conclusion

Communication and swallowing disabilities following sepsis are common, with impacts on the individual across the lifespan, with a wide variety of costs and consequences more broadly on society globally. Co-design and development of a multidimensional sepsis research agenda should include a focus on early identification and management for new and ongoing communication and swallowing disabilities associated with sepsis, and should involve consumer participation. In this paper, we have outlined some of the future steps and opportunities for this to be realised by advancing sepsis management considering progress towards good health and well-being (SDG 3), quality education (SDG 4) and reduced inequalities (SDG 10). Collaborative multidisciplinary management of sepsis during and after an ICU admission should extend well beyond domains of health. It should include social and economic domains; provision of person-centred care in palliative care management; and monitoring and supporting rehabilitation, return to work, and social participation for sepsis survivors and their families. Provision of service, education, and training of a multidisciplinary health workforce is required to meet gaps in ICU sepsis services focusing on swallowing and communication disability. This, along with collaborative advocacy from speech-language pathology professional associations and critical care societies should help to reduce inequalities to address sepsis, swallowing and communication disability as a global health priority.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

A Freeman-Sanderson was supported by a University of Technology Sydney Faculty of Health Grant.